Flashcards in Pediatric Anesthesia Week 3 Flash Cards Deck (129):
What is the most common cyanotic congenital heart disease? How common? What is its classification?
- Tetrology of Fallot
- Accounts for 6- 11% of congenital heart disease
- "Simple" Right- to- Left Shunt
What are 2 major characteristics of Tetrology of Fallot? What are the other characteristics?
- RV-Outlet Tract Obstruction (infundibular obstruction/ spasm)
- Overriding Aorta
- RV Hypertrophy
What is an "Overriding Aorta"?
In TOF, the aorta is displaced to the right so that it appears to arise from both ventricles and straddles the VSD
What are "tet spells"?
In TOF, hypercyanotic spells occur when there is an increase in RIGHT-to-LEFT shunting (increase in PVR)
What relationship determines the degree of RIGHT-to-LEFT Shunting, ergo the degree of hypoxemia in a patient with TOF?
The relationship between RV-Outlet Tract Obstruction (RVOTO) AND Systemic Vascular Resistance (SVR)
What causes "tet spells"? What triggers "tet spells"?
Unclear, but they occur during:
- Crying -Feeding
- Anesthesia/surgical stimulation -Metabolic acidosis
- Increased PaCO2 - Circulating catacholamines
How do you treat TOF- Hypercyanotic "tet spells"?
- 100% O2
- Hyperventilation (decrease in eTCO2 will decrease PVR)
- Increase PRELOAD (IVF)- give fluid deficit early or give bolus of 10 ml/kg of crystalloid
- Vasoconstrict with Neosynephrie (to INCREASE SVR to reverse R-L shunt)
- Use a BETA-BLOCKER to relax infundibular spasm and reduce HR
When is surgical repair of TOF considered? What is done?
- Complete repair which involves closure of the VSD and relief of RV outlet tract obstruction (RVOTO)
What is the name of the surgical procedure to repair a TOF?
Modified "Blalock-Taussig (BT) Shunt" to improve systemic-to-pulmonary shunt and improve pulmonary blood flow
The Modified "Blalock-Taussig (BT) Shunt" shunts from the ______ ________ to the _______ _______, creating a _______ blood flow.
- Subclavian Artery
- Pulmonary Artery
What are some anesthetic considerations for a TOF repair?
- PRESEDATE to prevent crying on induction increasing risk for "tet spells"
- A-Line is placed on the arm OPPOSITE to the side of the anastomosis ( Subclavian artery is going to be clamped).
- SNUG ETT with NO AIR LEAK
- Prepare for BLOOD TRANSFUSION potential
What is predominantly dependent on the size of PT shunts?
Postoperative pulmonary blood supply
How does post-operative blood supply effect the size of the BT shent?
- If the BT shunt is too small = Low saturation
- If the BT shunt is too large = Infant may develop heart failure/ pulmonary edema
- TEE intraoperatively will assess RV function
Pulmonary blood flow is also dependent on ? How?
- Systemic blood pressure
- The greater the blood pressure, the more blood flow toward the lungs, thus increase in saturation
*Postoperative ventilation may be required
Does blood shunt right-to-left or left-to-right through the VSD in Tetrology of Fallow (Cyanotic Heart Disease)?
Blood shunt RIGHT-to-LEFT, permitting unoxygenated blood to mix with oxygenated blood, resulting in CYANOSIS
What are goals of anesthetic management for the patient who has Tetrology of Fallot?
- Maintain intravascular volume and SVR
- AVOID increase in PVR
What pharmacologic agent decreases a right-to-left shunt?
Any drug that increases SVR, like Phenylnephrine, increases SVR and decreases right-to-left shunt
** An infant has Tetrology of Fallot (cyanotic heart disease). Which of the following arterial blood gas parameters will NOT typically be changed: PaO2, pH, PaCo2?
pH and PaCo2 typically maintain in the normal limits
PaO2 is usually markedly decrease (< 50 mmHg)
During the case, SpO2 decreases, apparently because of increased shunting. The patient has Tetrology of Fallot. What agents might be selected to decrease shunt and increase SpO2?
- Volume must be maintained with IV FLUID administration as hypovolemia increases the magnitude of the right-to-left shunt
- An alpha agonist, such as PHENYLNEPHRINE must be available
What change in SVR and PVR increase shunt in a patient with Tetrology of Fallot patient?
- Shunt increases when SVR decreases or PVR increases
- Volatile anesthetics, drugs that release histamine,
What drugs increase shunt in the patient with TOF by altering SVR or PVR?
Drugs that decrease SVR such as:
- Volatile anesthetics
- Histamine releasing drugs
- Ganglionic blockers
- Alpha blockers
- Vasodilators, like Nitroprusside, that decrease SVR
Drugs that increase PVR such as:
- Nitrous Oxide (N2O), detreimental to children with right-to-left shunts
List 3 conditions that increase right-to-left shunt (Tetrology of Fallot)?
List 4 congenital heart defects involved with Tetrology of Fallot (cyanotic heart disease)?
- Right Ventricular Outflow Tract (RVOT) Obstruction i.e. Pulmonary Stenosis
- RV Hypertrophy
- Overriding Aorta- Dextroposition (to the right) of the aorta with overriding of the VSD
What is a Complex Shunt? What are the 5 types?
Mixing of pulmonary and systemic blood flow with cyanosis
1. TGA- Transposition of Great Arteries
2. Truncus Arteriosus
3. DORV- Double-Outlet Right Ventricle
4. HLHS- Hypoplastic Left Heart Syndrome
5. TAPVC- Total Anomalous Pulmonary Venous Connection
What does TGA stand for? How is it defined?
- Transposition of the Great Vessels (Arteries)
- The Aorta arises from the RIGHT VENTRICLE, and the Pulmonary Artery arises from the LEFT VENTRICLE. The coronary arteries are shown arising from the aorta
*These children are cyanotic
What is the only way children with TGA can receive oxygenated blood?
Through their Patent/ Persistant Foramen Ovale (PFO) and Patent Ductus Arteriosus (PDA)
What kind of circulation is TGA considered? Does mixing occur? How often?
- Parallel Circulation: Two circulations run parallel rather than in series
- Yes, through the PDA and/or VSD
- Present in 25%
What is done to ensure ductal patency is maintained in a patient with TGA?
- An infusion of PROSTAGLANDIN E1
- Urgently performed BALLOON ATRIAL SEPTOSTOMY
- An Atrial Septal Defect is created to buy time
What procedure is performed to correct Transposition of Great Arteries? What vessels are disconnected?
- An "Arterial Switch" is performed
- The Aorta, Pulmonary Artery, and Coronary Arteries
During an "Arterial Switch", the Pulmonary Artery is moved ________ to the Aorta. The Aorta is connected to the _____ ventricle. The Pulmonary Artery is connected to the _______ ventricle. The ________ ________ are connected to the _________ _____.
- Coronary Arteries
- Neo-Aortic Root
** What is considered the most crucial part of a successful outcome of an "Arterial Switch" procedure?
The successful anastomosis of the Coronary Arteries to the Neo-Aortic Root
When should an "Arterial Switch" be performed for a patient with TGA? What results if left untreated? If treated, what is the outlook on life?
- Often required early at 2 to 3 weeks of life
- If untreated, patient will usually die within 1 year due to HYPOXIA and HEART FAILURE.
- If successful, child can expect to live a normal life
What risks do these patients have post-Cardiopulmonary Bypass?
- Inherently poor Left Ventricle
- Poor Myocardial Protection
- Poor Coronary Transference
- Coronary Air
- Pulmonary Hypertension
- Left Atrial Dilation (caution with fluid boluses)
This Complex Shunt has a common truncal valve and mixing of oxygenated and deoxygenated blood
How common is Truncus Arteriosus?
Rare, usually only 1 % of Congenital Heart Defects
What is a characteristic of Truncus Arteriosus?
- Common arterial outlet for Aorta and Pulmonary Artery associated with SINGLE VALVE and VSD
- Mixed blood at arterial level with HIGH PULMONARY BLOOD FLOW leading to PULMONARY HYPERTENSION and eventually HEART FAILURE
How is Truncus Arteriosus surgically treated?
SEPARATION of PULMONARY circulation from SYSTEMIC circulation and close VSD with a VALVED CONDUIT
What is the post-operative mortality rate in surgically treating Truncus Arteriosus? What reasons?
High, 5-25%, due to:
- Truncal Valve Stenosis
- Coronary Abnormalities
- Pulmonary Hypertensive Crisis
- Low Birth Weight
This Complex Shunt has BOTH of the GREAT ARTERIES (Pulmonary Artery and Aorta) arising from the morphologic RIGHT VENTRICLE, often due to a LARGE VSD
Double Outlet Right Ventricle (DORV)
How common is Double Outlet Right Ventricle (DORV)?
Rare, around 1 % of Congenital Heart Defects
What 2 major genetic strands are associated with Double Outlet Right Ventricle (DORV)?
Trisomy 13 and Trisomy 18
Trisomy 13 and Trisomy 18 are associated with which Complex Shunt?
Double Outlet Right Ventricle (DORV)
If Pulmonary _______ is present, DORV resembles the physiology of ________ of ________.
- Tetrology of Fallot
How much does the Pulmonary Valve have to be stenosed in order for DORV to resemble Tetrology of Fallot?
Characteristics of this Complex Shunt include a VERY SMALL UNDERDEVELOPED LEFT VENTRICLE
Hypoplastic Left Heart Syndrome
What are characteristics of Hypoplastic Left Heart Syndrome?
- Very small underdeveloped LEFT VENTRICLE
- Mitral & Aortic valve STENOSIS/ATRESIA
- Hypoplastic Aortic Arch
- SINGLE VENTRICLE (RIGHT VENTRICLE)
How does pulmonary blood flow in patients with Hypoplastic Left Heart Syndrome (HLHS)? Systemic blood flow?
- Pulmonary blood flow from Left Atrium (LA) via Atrial Septal Defect (ASD) to Right Atrium (RA) and Right Ventricle (RV)
- Systemic blood flow from RV to Pulmonary Artery (PA) to Aorta via Patent Ductus Arteriosus (PDA)
How is blood supplied to the systemic circulation in patients with Hypoplastic Left Heart Syndrome (HLHS)?
The Patent Ductus Arteriosus (PDA) is the only flow to the systemic circulation (arising from the Pulmonary Artery to the Aorta)
What is the epidemiology of Hypoplastic Left Heart Syndrome (HLHS)? When it is diagnosed?
- In the U.S, 2 out of 10,000 live births
- Usually during prenatal diagnosis
How do neonates present when suspecting HLHS?
- Systolic Murmur
How many surgeries must be performed to convert HLHS? What is it converted into?
- SINGLE-VENTRICLE TYPE CIRCULATION
What are the 3 procedures done to correct HLHS, starting with the 1st procedure?
1. Norwood (Neo-Aorta and BT Shunt)
2. Bidirectional Glenn, aka Norwood Stage II (Passive Pulmonary Blood Flow from SVC)
3. Fontan, aka Norwood Stage III (Passive Pulmonary Blood Flow from SVC and IVC)
What is the Fontan Procedure? What age group is it performed on? What is its outcome?
- The 3rd and FINAL procedure to correct HLHS, also known as Norwood Stage III.
- Connects the IVC with the PA via a CONDUIT
- A FENESTRATION is shown between the
CONDUIT and the RIGHT ATRIUM
- Around 3-4 years of age
- Passive Pulmonary blood flow from Superior and Inferior Vena Cava
What is the Norwood Procedure? What age group is it performed on? What is its outcome?
- The 1st procedure to correct HLHS, creation of NEO-AORTA and placement of Blalock-Taussig (BT) Shunt for passive pulmonary blood flow
- Around 2 to 3 months of age
During a Norwood Procedure, the branches of the pulmonary _______ are ________ from the pulmonary trunk.
During a Norwood Procedure, these 2 procedures performed are the only blood supply to the lungs and shunt either from the Subclavian Artery or from the Right Ventricle
Blalock-Taussig Shunt (from the Subclavian Artery)
Sano Modification (from the Right Ventricle
The BT Shunt and the Sano Modification are considered _____ _____ _____ and are dependent on _______.
- Passive blood flow
During a Norwood Procedure, how does a neonate present? What are their O2 saturations like?
They are cyanotic and O2 saturations are usually around 70-80%
What is the MAJOR anesthetic considerations for the Norwood procedure? What are others?
- Essential to maintain the balance between Pulmonary Vascular Resistance (PVR) and Systemic Vascular Resistance (SVR)
Why is it essential to maintain the balance between PVR and SVR during a Norwood Procedure?
If PVR decreases, blood flow will directed away from the systemic circulation and the lungs will be flooded leading to hypotension, hypoperfusion, and acidosis
If PVR increases, blood flow will be directed away from the lungs decreasing O2 saturation, increasing cyanosis.
How do you maintain balance between PVR and SVR during a Norwood Procedure?
Keep neonate SPONTANEOUSLY breathing with FiO2 of around 21 % and maintain a Prostaglandin E1 INFUSION to maintain ductal patency to keep PDA open! Keep a normal to High PaCO2 to maintain PVR.
Oxygen is a _____ and should be used ________ in Congenital Heart Disease patients.
_______ causes pulmonary vasoconstriction and pulmonary vascular smooth muscle (VSM) ________, BUT cause systemic __________ and systemic vascular smooth muscle (VSM) _________.
What are 2 factors that are potent stimuli for increase PVR?
Hypoxia and Acidosis
The addition of inspired O2 can lead to a reduction of pulmonary vascular resistance, how will it effect pulmonary blood flow?
May increase pulmonary blood flow in the presence of a systemic to pulmonary shunt
The addition of inspired O2 in conditions of DECREASED pulmonary blood flow can lead to this?
Improvement of O2 delivery by increasing O2 content
The addition of inspired O2 in situations of INCREASED pulmonary blood flow (i.e. residual VSD, large PDA, HLHS), can lead to this?
The increase in pulmonary blood flow occurs at the expense of systemic blood flow and reduction of systemic oxygen will occur (i.e. cyanosis)
What is the role of Prostaglandin in the fetus? What occurs after birth?
- Circulates in the fetus' bloodstream and keeps the Ductus Arteriosus (DA) open and patent
- After birth, Prostaglandin production decrease, plus increased O2 tension will close the Ductus Arteriosus
What drug do we give to keep the Ductus Arteriosus patent? What do we give to close it?
- Prostaglandin E1 Infusion
What are some anesthetic considerations for a Norwood procedure?
- High-dose opioid technique
- Venous access via femoral or umbilical vein (avoid IJ vein)
- Post-operative myocardial dysfunction is common
- Sternum remains open
Why do you want to avoid the Internal Jugular vein for access during a Norwood Procedure?
For future Bi-directional Glenn Shunt (Norwood Stage II) procedure
How long does the sternum remain open after a Norwood procedure?
What drugs would you administer in order to balance SVR and PVR after Cardiopulmonary Bypass?
A combination infusions of:
What is the Bi-directional Glenn Shunt (Norwood Stage II) procedure? At what age is it usually performed on? What is the outcome?
- The 2nd procedure to correct HLHS, the creation of PASSIVE PULMONARY (PA) BLOOD FLOW from SUPERIOR VENA CAVA (SVC)
- Around 1 to 1 1/2 years of age (dependent on developmental state)
- The Blalock-Taussig (BT) Shunt is disconnected and the Glenn Shunt is created by connecting SVC to PA
What are the other names for a Norwood Stage II?
- Bi-Directional Glenn Shunt
What are some anesthetic considerations for a Bi-Directional Glenn Shunt?
- Early extubation desired
- Maintain venous return to increase PRELOAD
- Keep Hematorcrit GREATER THAN 30
- Attach external DEFIBRILLATOR pads in place
- Now you can administer 100% FiO2
Why is early extubation desired with a Bi-directional Glenn Shunt? What else would you want to avoid?
- Positive intrathoracic pressure reduces flow in the Glenn Shunt
- Avoid PEEP or HYPERVENTILATION which will DECREASE venous return and DECREASE pulmonary blood flow
During a Fontan procedure, it is essential that the PVR remains... and why?
Low, any increase in PVR will dramatically reduce pulmonary blood flow and eventually reduce cardiac output
What is another name for the Fontan procedure?
Norwood Stage III
What is the purpose of creating a fenestration in a Fontan procedure?
Should PVR rise, blood will be directed to the Right Atrium and allow cardiac output to be maintained. So child may become cyanosed but cardiac output is maintained.
Overtime, children with HLHS post correction will eventually need a .......
Heart transplant d/t right ventricular failure
What are some anesthetic considerations for a Fontan procedure?
- Will require Cardiopulmonary Bypass, BUT WITHOUT Aortic cross-clamping
- PVR remains low post-operatively
- Minimize atelectasis (NO often used)
- Early extubation beneficial
- More fluids may be required early post-op
What does TAPVC stand for?
Total Anomalous Pulmonary Venous Connection
What occurs in a Total Anomalous Pulmonary Venous Connection?
4 Subtypes. The main arteries are removed. The pulmonary veins drain via the INNOMINATE vein to the RIGHT ATRIUM. There is also an ATRIAL SEPTAL DEFECT.
What kind of shunt occurs in TAPVC? How to patients present?
- Right to Left shunt occurs
- Tachypnea (depending on size of ASD)
- Pulmonary hypertensive (from veins being obstructed)
- Reduced pulmonary blood supply
What are the 4 subtypes of TAPVC?
What is a Total TAPVC?
Refers to all 4 pulmonary veins draining into anomalous site (either SVC, IVC, or RIGHT ATRIUM). A "partial" only a subset of pulmonary veins drain into anomalous site, the rest in the LEFT ATRIUM
What is a Supracardiac TAPVC?
Refers to ALL 4 pulmonary veins drain into the Superior Vena Cava
What is a Infracardiac TAPVC?
Refers to ALL 4 pulmonary veins drain into the Inferior Vena Cava
What is a Cardiac TAPVC?
Refers to ALL 4 pulmonary veins drain into the Right Atrium via the CORONARY SINUSES
What are patients with TAPVC at risk for? What maybe required post-operatively?
- Heart failure
- Pulmonary edema
- Pulmonary hypertension
- Nitric Oxide
What are the 4 types of Obstructive Lesions?
1. Pulmonary Stenosis
2. Aortic Stenosis
3. Mitral Stenosis
4. Coarctation of Aorta
In Aortic Stenosis, obstruction of the LV outflow tract (LVOT), can be either...
How common is Congenital Aortic Stenosis?
Accounts for 10% of Congenital Heart Diseases
Not managing the balance of O2 supply and demand can lead to?
- Impaired coronary blood flow
- Low coronary perfusion pressure
- LV subendocardial ischemia
- LV Hypertrophy
- Risk of LV failure
At what age are pediatrics with Aortic Stenosis at risk for sudden death?
Younger infants, usually the first 3 months of life
How is Aortic Stenosis treated?
- Open Cardiopulmonary Bypass
- Transluminal balloon angioplasty in cath lab
What are some complications with Urgent Valvuloplasty?
- Ventricular fibrillation
- Aortic incompetence
- Residual aortic stenosis
What are some anesthetic considerations with Valvuloplasty?
- Maintain balance between O2 supply and demand
- Maintain normal HR (avoid tachycardia or bradycardia)
- Maintain SVR to preserve coronary perfusion
- Avoid HTN and myocardial depression
* Have resuscitation drugs available!!
What does SBE stand for?
Subacute Bacterial Endocarditis
Who is considered the highest risk for adverse outcomes resulting from Subacute Bacterial Endocarditis?
1. Completely repaired cyanotic CHD patient with device within past 6 months
2. Unrepaired, cyanotic CHD patient
3. Cardiac transplantation recipients w/ cardiac valvular disease
4. CHD patient with history of endocarditis
Patients with "Highest Risk" should receive prophylaxis antibiotics prior to what procedures?
- Dental procedures
- Respiratory tract procedures
- Procedures on infected skin
- Procedures on tissue just under the skin
- Procedures on musculoskeletal tissue
Patients with "Highest Risk" will NOT receive prophylaxis antibiotics prior to these procedures?
What are the prophylaxis antibiotics?
- Amoxicillin PO 50 mg/kg
- Ampicillin IM/IV 50 mg/kg
- Cefazolin IM/IV 50 mg/kg
- Ceftriaxone IM/IV 50 mg/kg
If patient is allergic to PCN/Ampicillin give:
- Clindamycin IV 20 mg/kg
What is the drug of choice and dosing for prophylaxis for pediatric endocarditis?
Amoxicillin PO 50 mg/kg, 1 hour prior to procedure
Potent volatiles (reduce/increase) SVR more than PVR
What 2 techniques decrease PVR?
- Increased FiO2 (100%)
- Hyperventilation to pH of 7.6 (Decrease in eTCO2 causes decrease in PVR)
What factors or techniques increase PVR?
- PEEP - Hypoxemia
- Acidosis - Hypercapnia
- Hypothermia - Atelectasis
- Low FiO2 (less than 30%) - Stress response
- Stimulation or Light anesthesia
What is the usual cause of persistent pulmonary hypertension (persistent fetal circulation)? Is shunt associated with left-to-right or right-to-left?
- Hypoxia and acidosis
Why is it important to avoid air bubbles in IV fluids in children?
Children in right-to-left shunts have potential for air bubbles to directly be shunted into the systemic circulation causing stroke or air obstruction. Even patients with left-to-right shunts can transiently reverse their shunts (right-to-left) during coughing or Valsalva maneuver
What is the anesthetic volatile agent of choice on induction of pediatrics?
Sevoflurane < 1.5 MAC
How do patients with Congenital Heart Defects respond to decreasing HR with Sevoflurane induction?
- Reduced CO
*All leading to a rise in PVR
What is the anesthetic plan for induction on young infants with severe CHD?
- IV induction with high-opioid doses (3-5 mcg/kg of Fentanyl or more)
- Low dose SEVO or ISO
What can rapid uptake of Halothane cause?
- Significant hypotension
*Not so popular with cardiac anesthesia
Is Nitrous okay to be used on induction in cardiac anesthesia? How about during maintenance with CHD patients?
Yes. 70% of N2O for induction with Sevoflurane.
No, because of the increased risk of intravascular air emboli and potential increase of PVR.
* Less than 50% of N2O has little effect on PVR in infants
In what conditions should N2O be avoided? Why?
- Limited pulmonary blood flow
- Pulmonary hypertension
- Depressed myocardial function
* It mildly decreases CO in infants
Can Ketamine be an induction agent of choice? When is it not? Normal dose? How does it effect PVR?
Good analgesic agent. It increases HR, BP, and CO (stimulates release of endogenous catacholamines)
Poor choice if tachycardia is undesired (i.e. Aortic stenosis)
Dose is 1-2 mg/kg
Mildly increases PVR in children with CHD
Why is Etomidate an induction agent of choice? Why is there an increased mortality rate with Etomidate infusions?
Short acting, has little effect on BP, HR, or CO
Due to Adrenal suppression
*Inhibition of steroid synthesis can occur also after a single dose
How does inhaled Nitric Oxide work? How is it adminstered? What should patients be monitored for with long-term use?
- Acts on the Guanylate Cyclase to produce pulmonary vascular smooth muscle relaxation
- Adminstered in 1- 80 ppm (usually 20-40 ppm)
- Blood methemoglobin concentration
What is Flolan? What does it do? What is its half life? Side effects? Contraindications? What is the administration increments?
- Naturally occurring Prostaglandin
- Potent vasodilator of both SVR and PVR
- Used in treatment of primary pulmonary hypertension
- Inhibition of platelet aggregation
- Half life of 6 minutes
- Flushing of skin, headaches, nausea/vomitting, hypotension
- AVOID ABRUPT INTERRUPTION OF FLOLAN IV (leads to rebound pulmonary hypertension)
- DO NOT USE FOR IV INDUCTION
What is a Valvectomy? Valvotomy? Valvuloplasty?
- Valvectomy is a valve excision
- Valvotomy is an opening of stenotic valve
- Valvuloplasty is valve repair
What does preductal or postductal coarctation of aorta refer to?
Coarctation of the aorta refers to a discrete narrowing of the aorta immediately distal to the origin of the left subclavian artery
- Preductal coarctation= the narrowing occurs proximal to the opening of the ductus arteriosus
- Postductal coarctation= Supposedly present in adulthood long after the closure of the ductus arteriosus
Should upper extremity blood pressure be monitored in the neonate with preductal coarctation of the aorta on the right or left arm?
Best observed in the RIGHT RADIAL ARTERY
Where are pulse oximeters placed on the neonate to monitor preductal and postductal oxygenation?
PREductal- RIGHT hand or finger
POSTductal- LEFT foot or toe
What is the purpose of a preductal oximeter in the neonatal patient undergoing cardiac surgery?
A better index of the neonatal cerebral oxygenation
Identify the BEST site to obtain arterial blood gases from the neonate?
Best from the RADIAL ARTERY
PREDUCTAL O2 sats = CEREBRAL O2 sats
Which 2 sites should be avoided when obtaining ABG's?
Brachial or Femoral arteries
Has been associated with nerve damage and Femoral head necrosis and limb shortening
What is the anesthetic concern for the pediatric patient undergoing repair of a VSD WITHOUT significant pulmonary hypertension?
Should be managed to avoid arrhythmias, RV dysfunction, pulmonary vascular obstructive and paradoxical embolus